Download - Surgery for Lung Cancer Jocelyn McLean
Surgery for Lung Surgery for Lung CancerCancer
Jocelyn McLeanJocelyn McLean
Case Manager for Thoracic Case Manager for Thoracic SurgerySurgery
Surgery is offered to… Surgery is offered to…
CURECURE Early (Stage 1&2 Early (Stage 1&2
Primary NSCLC Primary NSCLC Solitary metastatic Solitary metastatic
lung tumorslung tumors DIAGNOSTICDIAGNOSTIC
APPROACH APPROACH Thoracotomy – open Thoracotomy – open
surgerysurgery
PALLIATEPALLIATE Advanced NSCLC – pleural Advanced NSCLC – pleural
effusionseffusions Metastatic pleural effusions Metastatic pleural effusions
from other primary from other primary Undiagnosed pleural Undiagnosed pleural
effusions – primary effusions – primary unknown unknown
DIAGNOSTICDIAGNOSTIC
APPRAOCHAPPRAOCH
Thoracoscopy – keyhole Thoracoscopy – keyhole surgerysurgery
For curative surgery - it’s as simple For curative surgery - it’s as simple
as …….as ……. Diagnosis of NSCLC or High Diagnosis of NSCLC or High
suspicionsuspicion PET -ve supporting clinical history PET -ve supporting clinical history Increasing size over 3 monthsIncreasing size over 3 months
Localised disease (within the chest)Localised disease (within the chest)
Fit enough for an operationFit enough for an operation Anaesthetic Anaesthetic Respiratory function / capacityRespiratory function / capacity
Technically possible - IF IN DOUBT – Technically possible - IF IN DOUBT – ASK THE LUNG SURGEON !! ASK THE LUNG SURGEON !!
Stopped smoking min of 4 weeks Stopped smoking min of 4 weeks (total cessation)(total cessation)
General principlesGeneral principles SafeSafe Short anaesthetic timeShort anaesthetic time Risks include Risks include
bleeding, bleeding, infection, infection, cardiovascular event, cardiovascular event, Air-leak Air-leak
Low mortalityLow mortality Overall Overall (1%)(1%) Pneumonectomy (Pneumonectomy (2%)2%) More deaths from those More deaths from those
with advanced with advanced malignancymalignancy
Maximise health prior to Maximise health prior to opop
Understand procedure Understand procedure and expected recovery - and expected recovery - short LOSshort LOS
Effective pain relief Effective pain relief Effective physiotherapyEffective physiotherapy Early removal of ICC- Early removal of ICC-
minimise air leaksminimise air leaks Early mobilisationEarly mobilisation Reliable ICU/respiratory Reliable ICU/respiratory
supportsupport
What makes surgery amenable to more What makes surgery amenable to more
patients?patients? Double lumen ETT Double lumen ETT
1 lung ventilation1 lung ventilation
Stapling techniquesStapling techniques GlueGlue Knowledge from Knowledge from
LVRSLVRS
Older patients, worse Older patients, worse lungs, shorter lungs, shorter operationoperation
Insertion of a Double Lumen TubeW. John Russell 17th May 2000
Routine – pre-op for Routine – pre-op for surgerysurgery
Respiratory assessment Respiratory assessment RFT/spirometry, clinical assessment, What op ? RFT/spirometry, clinical assessment, What op ?
pneumonpneumon Stop smokingStop smoking Stop anticoags- Plavix, Warfarin, Asprin Stop anticoags- Plavix, Warfarin, Asprin Maintain respiratory medsMaintain respiratory meds Other co morbidities controlled – Diabetes, Other co morbidities controlled – Diabetes,
cardiac, cardiac, Preadmission clinic- bloods, ECG, CXR,G&H, Preadmission clinic- bloods, ECG, CXR,G&H,
MRSA screen, Physio consult, History, MRSA screen, Physio consult, History, PathwayPathway
Day of surgery admissionDay of surgery admission
Intentions of surgeryIntentions of surgery
Surgical resection Surgical resection offers only chance of a offers only chance of a cure.cure.
Gold standard is Gold standard is lobectomy, bi-lobectomy lobectomy, bi-lobectomy or pneumonectomyor pneumonectomy
Formal lymph node Formal lymph node resection.resection.
If cure is intended If cure is intended but resp capacity but resp capacity prevents lobe etc prevents lobe etc then wedge then wedge resection or resection or segmentectomy.segmentectomy. price is > chance of price is > chance of
local recurrencelocal recurrence
If the intent is palliative..If the intent is palliative..….….
Thoracoscopic approach.Thoracoscopic approach.
Improve QOL – when reasonable quantity (time) is Improve QOL – when reasonable quantity (time) is likely.likely.
Symptom control – shortness of breath, painSymptom control – shortness of breath, pain Optimize re-expansion of lung Optimize re-expansion of lung
Carries significant risk of post operative morbidity Carries significant risk of post operative morbidity and mortalityand mortality
Obtain diagnosis - significant if young / Obtain diagnosis - significant if young / compensation compensation
Right Lower Lobectomy Left Upper Lobectomy
Malignant Pleural EffusionMalignant Pleural Effusion - mesothelioma - mesothelioma
Thoracoscopy pleurodesis only
Thoracotomy6 Weeks after decortication